Provider Demographics
NPI:1720343346
Name:CORRAL DELACRUZ, JESSICA (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CORRAL DELACRUZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:CORRAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:536 W MARTINTOWN RD
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-1101
Mailing Address - Country:US
Mailing Address - Phone:803-510-0007
Mailing Address - Fax:803-510-0144
Practice Address - Street 1:536 W MARTINTOWN RD
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-1101
Practice Address - Country:US
Practice Address - Phone:803-510-0007
Practice Address - Fax:803-510-0144
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35149208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics